1. Have you reviewed a copy of the Safe Sanctuary Policy of Calvary Church (2014)?

Yes No

2. Have you ever filled out this questionnaire for this church?

Yes No

If no, please go to questions #3 through #10 below.

If yes, give the date:

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Month
-
Day Year

Date

Have any answers changed since you filled out that copy?

Yes No

If no, please initial and submit this form. If yes or you are unsure, please answer questions #3 through #10 below.

3. Have you ever been accused, in a written and signed statement, of sexual misconduct with a child or a youth?

Yes No

4. Have you ever been accused, in a written and signed statement, of sexual misconduct with an adult?

Yes No

5. Have you ever been dismissed from any position, volunteer or salaried, because of accusations of sexual misconduct on your part?

Yes No

6. Have you ever resigned from any position, volunteer or salaried, because of an accusation of sexual misconduct on your part, or to avoid being dismissed because of an accusation of sexual misconduct on your part?

Yes No

7. Other than the above, is there any fact or circumstance involving you or your background that would call into question your being entrusted with the supervision, guidance, and care of young people?

Yes No

8. Have you ever been restricted by a church or other organization from involvement with youth or children?

Yes No

9. Have you ever been arrested or convicted of a crime?

Yes No

10. Have you ever received an arrest or citation for Driving Under the Influence or Driving While Intoxicated?

Yes No

If your response to any of the questions #3 through #10 is "yes", please provide in the comments section below all details regarding each accusation of sexual misconduct, restriction or criminal arrest that has been made with respect to you. The application will not be processed until such information is provided.

By providing my initials here, I certify that the answers I have provided on this questionnaire are true and accurate to the best of my ability. I understand that false answers as well as the failure to initial this questionnaire will result in my application being denied.

Initials:
*

Date:

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Month
-
Day Year

Date

Please provide three adult references (names, addresses, phone numbers) of persons who are not related to you by blood, marriage or other family relationship and are not employed or supervised by you, who can, to the best of their ability, provide statements in support of your good character and clean record in regard to sexual misconduct with children, youth, and adults.